In September 2017, the Institute for Healthcare Improvement announced the results of a recent survey, which found that 21% of Americans had experienced medical errors. An even higher percentage of Americans, 31%, reported that their loved ones had been impacted by a medical error.
In addition to these interesting statistics, two of the survey findings particularly caught my attention.
First, over 8 out of 10 people surveyed stated a belief that families and patients share a role in patient safety, along with healthcare providers, hospital leaders and administrators. Second, when surveyors asked for details about the medical errors they experienced, people identified an average of at least seven different factors.
Serious healthcare injuries typically involve multiple medical errors
These findings mirror my observations from speaking with countless patients and family members in my Houston, Texas law practice as a medical malpractice attorney.
I find it hard to think of an example of a case that I have handled where there is a serious patient injury caused by a single, solitary medical error. Instead, there are almost always multiple errors or failures by multiple doctors and nurses that play a role. I think an example may help to illustrate this.
I am working on a case now where in otherwise healthy, active patient had a lumbar fusion surgery in his back. One of the known complications of the surgery, even with good care, is the formation of hematomas (an aggregation of blood cells) that can compress the spinal cord. Of course, when there is spinal cord compression, it is an emergency situation that requires a quick return to the operating room to relieve that pressure. Thus, the standard of care requires the surgeon and nursing staff to be alert for any sign of paralysis, or things not working right, from the waist down.
About a day and one-half after the surgery, the nurses noted that this patient could not empty his bladder and felt numb from the waist down. Later, the nurses documented that his neurological exam for his lower extremities was abnormal. They waited over seven hours before notifying the surgeon of either finding. This was certainly an error on the part of the nursing staff.
The neurosurgeon ordered an MRI, presumably to check for a hematoma that might be compressing the patient’s spinal cord. Despite the classic signs of spinal cord compression that the nurses finally reported to him, the neurosurgeon made the MRI order routine, rather than stat, or as soon as possible. That was a medical error on the neurosurgeon’s part.
Another seven hours passed before the neurosurgeon actually saw the patient. During that time period, the nurses did nothing to make sure that the MRI got done. That was another error on their part. By the time the neurosurgeon saw the patient, the MRI still had not been done. That was an error on the part of the radiology department. Oddly, the neurosurgeon decided to cancel the MRI altogether. Of course, that was yet another error on the neurosurgeon’s part.
Sadly, as a result of these combination errors, this patient has permanent neurological injuries, called saddle anesthesia, or cauda equina syndrome, including the loss of bowel, bladder, and sexual function, and a loss of sensation from the waist down.
Role of the patient and family
I found it interesting that the recent survey results showed that almost everyone agrees that patients and family members have a role in patient safety. I wonder, though, if most people realize precisely how important that roleis.
Most doctors and nurses do their best to take care of their patients, but all of them have divided attention. They are responsible for the care of multiple patients at the same time. Patients and family members, though, can devote their singular attention to one person. In addition, they know the patient, and the patient’s normal behavior, or baseline, better than any healthcare provider ever will.
For these reasons, patients and family members often are the first people to know when something is wrong. If you find yourself in this position, speak up and speak often.
In my experience, nurses frequently try to console and calm patients and their families by reassuring them that nothing is wrong. Unfortunately, this exercise often takes the place of nurses going through a process of assessing the patient and communicating findings to a physician.
When this happens, and a doctor eventually comes to see the patient, the patient and family members often do not repeat all of their complaints and observations. After asking many clients why that is the case, I have found the most typical response is that they thought that the nursing staff had already passed along that information to the doctor.
Speak up and speak often.
I have some recommendations that will help you improve patient safety.
First, I recommend that hospitalized patients have a friend or loved one with them at all times.
Second, someone should keep a journal of significant things that happened in their care. This includes names of healthcare providers, orders, results, and medications, as well as any changes observed in the patient’s status or behavior.
Third, any time there is a negative change in the patient’s status, tell the nurse and ask what the nurse will do with the information. If you want to speak with the doctor, be specific in that request.
Fourth, when a doctor or new nurse comes to the patient room, after a change in the patient’s status, presume that they have not been informed of the patient’s deterioration. Use the journal to share the details that you have seen.
Finally, if you find that your nurse is not informing the physician of your concerns, ask to speak with a nursing supervisor or charge nurse, and then share all of the information, starting from the beginning.
We are here to help
If you or a loved one has been seriously injured as a result of medical malpractice, call Painter Law Firm, in Houston, Texas, at 281-580-8800, for a free consultation about your potential case.
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Robert Painter is an attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who focuses his law practice on filing medical malpractice and wrongful death lawsuits, on behalf of patients and their families.
